Dying : a good death in Emergency Medicine Introduction of the Liverpool Care Pathway to Emergency Medicine

1. Dying : a good death in Emergency MedicineIntroduction of the Liverpool Care Pathway to Emergency Medicine Dr Russell Duncan Emergency Medicine NHS Tayside

2. What is the LCP? The Liverpool Care Pathway (LCP) is a multi-professional document which provides an evidence-based framework for end of life care. It is particularly suited for acute areas where managing death is not the primary role.

3. What is the LCP? • An Integrated Care Pathway • The modified LCP is 6 pages • designed to be the final documentation in a patients notes

4. Why use the LCP in EM? • From around 2001 we were aware of our increasing role in the final hours’ care of dying patients 1 • Audit in 2003 • Approximately 40 dying patients in our short stay ward • High standards of care as perceived by staff and relatives • Lack of consistency in the care provided • Pedley D Johnston M. Death with dignity in the accident and emergency short stay ward. Emerg Med J. 2001; 18: 76-77

5. Why use the LCP in EM? • Advice was sought from our local palliative care team • We were aware that our patient group differs from hospice and inpatient cohorts • Our target group is those who are rapidly dying and expected to die within 24 hours • Our patients are typically unconscious and deteriorating • In 2005 we introduced a modified version of the Liverpool Care Pathway

6. How did we use the LCP in EM? • We used the LCP as a model for a shortened and amended version of the pathway • The LCP was reduced to 3 core areas • Entering the pathway • On the pathway • Post death administration

7. Using the LCP in EM • The starting point is MAKING THE DECISION THAT A PATIENT IS DYING • THIS IS CRUCIAL and needs to be made at a SENIOR LEVEL • The patient and their relatives are taken to a dedicated “TLC” area with trained staff

8. Using the LCP in EM The care pathway does not preclude the recovery of some patients in certain circumstances If there is an improvement or unexpected change in the patient’s condition, the duty consultant or SpR is informed

9. Part 1 of the EM LCP Entry to the pathway must be approved by the duty EM Consultant and supported by the duty senior Nurse Demographics; prepopulated Additional information is added Diagnoses and examination is recorded

10. Part 1 of the EM LCP Decisions must be made Medications incl IV fluids and oxygen? Interventions are appropriate? Vital signs? Routine turning? Comfort turning?

11. Part 1 of the EM LCP Spiritual support is offered It is of utmost importance that the family fully understand the plan of care

12. Part 2 of the EM LCP • The period of admission • Goals • Monitored hourly • More frequently than the LCP • Achieved or variance with action noted

13. Part 2 of the EM LCP • Comfort Goals • Mouth and eye care, goal is to be moist and clean. • Elimination, goal is to be clean and comfortable. • Pressure area care, goal is the avoidance of pressure sores – usually turn for comfort. • Treatment Goals • Pain, goal is to be pain free on movement, appear peaceful and move only for comfort. • Agitation, goal is to be neither restless nor thrashing • Respiratory tract secretions, goal is to have quiet breathing. • Nausea and vomiting, goal is absence of both.

14. Part 3 of the EM LCP After death administration “Relative aware” Culturally aware

15. Medication Pain; Morphine Agitation; Midazolam Secretions; Hyoscinehydrobromide Nausea; Cyclizine or metoclopramide Intravenous Dilution 1mg/ml 50ml Baxter syringe and syringe driver

16. LCP in EM Piloted November 2005 Launched Spring 2006 The first year was audited Spring 2007.

17. Tayside final hours ICP audit Included All patients who died in the emergency department after a decision to withdraw active treatment was made Excluded Patients in whom resuscitation was ongoing on arrival and who were then pronounced dead Patients who died unexpectedly

18. Patients A total of 67 patients identified of which 61 had notes available for investigation 33 male : 34 female Age 20-96 years (median 77, mean 70.5)

19. Diagnosis • Most common diagnoses were acute traumatic head injury or non-traumatic intracranial bleed • 54% of total

20. Survival Survival from the time of decision to provide end of life care Median survival time was 2 hours (IQR 9.75 hours) ranging from 5 minutes to 99 hours. 63% had died within 6hrs, 80% within 12 hours, 86% within 18 hours and 89% within 24 hours. Patient selection can still be a problem

21. Survival 3 patients recovered sufficiently to leave the pathway All subsequently died in hospital

22. Medication 40 of 61 required medication during the period of care on the pathway. Morphine Median dose 2.5 mg/hr (IQR 5.8mg/hr) Midazolam Median dose 0.41 mg/h (IQR 0.84 mg/h) This is comparable with doses reported in the palliative care literature

23. Pathway goals The primary goals were achieved >95% of the time however for approximately 50% of patients the pathway documentation was incomplete. This appears to be directly related to the patients length of survival The group with incomplete documentation had a median survival of 45 minutes (26/30 survived <2 hours) The group with full documentation had a median survival of 10 hours

24. Pathway goals The appropriate discontinuation of current medications, medical interventions (ie blood tests) and vital sign recordings was documented 60% of the time This suggests that even when there was insufficient time to utilise the full pathway, some of the main principles were considered

25. What next • The 2006–7 audit revealed progress, but there were areas for improvement. • Documentation and general use of the pathway was covered by refresher sessions with all staff • Further survey of nursing staff involved in the pathway was completed in 2008 • This indicated that nursing staff feel the level of care provided to the dying patient has improved by the introduction of the modified LCP.

26. Summary Emergency Medicine has a significant role in the care of the acutely dying patient We have formalised care by adapting the Liverpool Care Pathway for use in the Emergency Department short stay ward We have had strong positive feedback from both the relatives of those cared for and from nursing staff

27. Publications • Paterson BC, Duncan RA, Conway R, Paterson F. Introduction of the Liverpool Care Pathway for end of life care to emergency medicine. Emerg Med J 2009; 26: 777 – 779. • Kinnon A, Paterson B, Duncan RA,Raitt M. Can we improve the care of patients dying in the Emergency Department? Nursing attitudes towards the introduction of a modified Liverpool Care Pathway. 12th International Conference on Emergency Medicine, San Francisco, USA. April 2008. Poster presentation. • Duncan RA, Paterson B.End of life care in the Emergency Department: an integrated care pathway to improve care of the dying patient. CEM Annual Scientific Conference, Sheffield. September 2007. Moderated poster presentation. • Pedley D Johnston M. Death with dignity in the accident and emergency short stay ward. Emerg Med J. 2001; 18: 76-77

28. Any Questions?